Brief statement of why accommodation is needed or the barrier removed:*

Date accommodation is needed:*

Date Format: MM slash DD slash YYYY

Signature*

Certification: I certify that I have a disability or medical condition that required reasonable accommodation, which will be met by acquiring the equipment, services or work adjustments described above.

Date:*

Date Format: MM slash DD slash YYYY

If person needed accommodation is not the individual completing this form, please provide a representative’s name, address and telephone number: